3
School of Public Health Medicine,
University of Newcastle, New South Wales, Australia

4
Africa Fighting Malaria, Durban,
South Africa

Corresponding
author: M Coetzee
(maureenc@nicd.ac.za)

In Africa today, the drive
towards controlling malaria is comparable with efforts made in
the 1950s and 1960s during the World Health Organization’s
Global Malaria Eradication Campaign. Unlike the Eradication
Campaign that ‘covered’ the globe but excluded Africa, the
current endeavours focus on Africa, but not to the exclusion
of the rest of the tropical and sub-tropical world. Major
donor agencies are partnering with African governments in an
attempt to curb transmission of malaria parasites, and in some
countries on the edges of the distribution of malaria, there
is talk of eliminating the disease. South Africa is at the
very southernmost fringe of malaria distribution on the
African continent and has a long history of intense malaria
control activities. This article looks at what South Africa
has achieved in the past and where it needs to go in the
future, not only to maintain the status
quo, but hopefully
to eliminate transmission of the disease within its borders.

S Afr Med J 2013;103(10 Suppl 2):770-778.
DOI:10.7196/SAMJ.7446

1. The early days

The causative agent of
malaria was determined in the 1890s by the individual works of
Laveran, Grassi and Ross, as a parasite belonging to the genus
Plasmodium and transmitted to humans by
anopheline mosquitoes.1 Prior to this, fevers were
associated with ‘bad air’ (in Italian ‘malaria’), swamps and other unsavoury
localities.

In South Africa (SA), the
first well-documented case of the devastating effects of
malaria was probably that of the Louis Trichardt trek to
Maputo, Mozambique in 1837 - 1838, when 20 of the 53 members
of the party died of malaria, including Trichardt’s wife. 2,3 Trichardt himself died of
malaria 6 months later. Laidler and Gelfand,4 in their book on the medical
history of SA, make brief reference to malaria being ‘a most
serious ailment in the Transvaal Republic’ and in the 1830s
immigrants to Natal ‘suffered great losses from malaria and
other fever’.5 In those early days, of course,
diagnosis was purely clinical and was based on the pattern of
high fever with attendant high mortality rates.

After the discovery in the
1890s that malaria was caused by a parasite transmitted by
anopheline mosquitoes, the next report on malaria in SA was by
Hill and Haydon6 on the 1904/05 malaria epidemic
in Natal. In Durban alone, between the end of January and end
of June 1905, 4 177 cases of malaria were recorded with
42 deaths (malaria had been declared a compulsory notifiable
disease in Durban in 1902).7 At the beginning of the
epidemic, blood smear examination showed mainly benign tertian
malaria (Plasmodium vivax), while later, as the epidemic
increased, cases of severe tertian malaria (P. falciparum) became prevalent. Quinine
tablets were used to treat the malaria cases. Extensive
mosquito surveys found a sporozoite infection rate of 9.1% in
Anopheles costalis (An.
gambiae s.l.)
collected inside houses and dissected within 2 days of
capture. Hill and Haydon6 stated that they were ‘unable
to advance any sound reason to account for this epidemic’,
there being no dramatic change in climatic factors compared
with previous years when no malaria transmission took place.a Their stated impression was
that the larvicidal measures implemented had no apparent
impact on the epidemic, and they concluded that ‘only the
prophylactic use of quinine appears to give promise’. Murison,8 however, in Ronald Ross’ book ‘The Prevention of Malaria’, provided his account of the
1905 epidemic and the subsequent antimalarial activities of
1906 - 1907. He reported that the larviciding and larval
source management in the borough of Durban had been very
successful compared with the areas outside of the borough
where malaria transmission continued unabated. After the 1905
epidemic in Natal, malaria again became rare and no cases were
reported from Durban up to 1918.

Also in Ross’ book is a
section on malaria control in SA along the railway line from
Pretoria to Delagoa Bay (Maputo, Mozambique). Bostock9 states that no attempt was made
to combat malaria until he was appointed District Surgeon in
Komatipoort in 1903. He goes on to describe the most amazing
and intense implementation of antimalarial measures he
organised that were funded by the Central South African
Railways. Every station, house and cottage from Waterval Onder
to Komatipoort was mosquito-proofed, mosquito breeding
habitats in the vicinity of the stations were ‘dealt with’,
free quinine was available and intense larval source
management carried out in the town of Komatipoort. Malaria
case figures presented for 1903 - 1905 show an overall
reduction of 87.5%.9

In 1921, Pratt-Johnson7 published a paper on the
distribution of malaria in SA and a mosquito survey of areas
around military hospitals. The military hospitals visited by
Pratt-Johnson and inspected for mosquito breeding were
situated in Cape Town, Durban, Potchefstroom and Pretoria
(Roberts Heights, now known as Thaba Tshwane). Two specimens
of An. costalis were collected from Roberts
Heights as larvae, almost certainly being Anopheles quadriannulatus. This species was described and
named in 1911 by F Theobald from material collected north
of Pretoria and it is one of the cattle-feeding, non-vector,
members of the An. gambiae complex in SA.

Flooding along the Orange River
in 1909 caused a severe epidemic in the districts of Gordonia,
Kenhardt and Upington (bordering on Botswana and Namibia),
stretching into Namaqualand and the Kalahari, and further east
into what is today the North West Province. No information was
available on the mosquito populations involved in this epidemic.

A small outbreak of malaria
occurred in February 1918 in a localised area in Durban,
presumed to have been initiated by a group of Indians
returning from East Africa and infecting locally breeding ‘An. costalis’. These cases were diagnosed on
blood smears as benign tertian (P.
vivax) malaria.7

In the Transvaal, vivax and falciparum malaria were
equally prevalent in the period under review, with P. vivax tending to occur more
frequently at higher altitudes on what is known as the
Middleveld, while P. falciparum was common in Lowveld areas.b

2. From the Roaring Twenties to the end of
World War II

The Department of Medical Entomology was established by the
South African Institute for Medical Research (SAIMR) in 1925
under the headship of Alexander Ingram.5 He was joined in 1926 by
Botha de Meillon (Fig. 1) (later to become head of the
department from 1931 to 1960) and together they undertook the
first extensive mosquito surveys of SA covering the Transvaal
and Zululand.10
Ingram and De Meillon11 confirmed the insecticidal
properties of pyrethrum, while De Meillon12,13
demonstrated the powerful influence that indoor spraying with
pyrethrum would have on malaria transmission (see below), this
being the forerunner of the World Health Organization’s (WHO’s)
global malaria eradication campaign over 20 years later.

Fig. 1. Botha de Meillon (1902 - 2000),
aged 80.

In 1930, two prominent
malariologists visited SA. The first was Sir Malcolm Watson, a
distinguished British scientist from the London School of
Hygiene and Tropical Medicine, who spent most of his time
fighting malaria in Malaysia. He visited SA on his way north
to mining communities in Northern Rhodesia (Zambia) in July
1930. 14 His major contribution to
malaria control in SA was to persuade the government that
malaria had economic significance, not just medical
importance.5 Malaria continued to devastate
some of the richest agricultural areas in SA for another 15
years.

Professor N H
Swellengrebel, another world-renowned malariologist, from the
University of Amsterdam, visited SA in the latter half of 1930
and was accompanied by De Meillon and Siegfried Annecke on a
tour of the Lowveld areas to investigate the malaria
situation. The comprehensive report that resulted from this
visit15 recommended the implementation
of ‘species sanitation’, this being the specific targeting of
malaria vector mosquitoes with control interventions,
excluding those mosquito species not involved in malaria
transmission. This required insight into the behaviour of the
malaria vectors and subsequently led directly to indoor
spraying with pyrethrum.13,16

Swellengrebel also
recommended the esta­blishment of a malaria station in
Tzaneen. The SAIMR, at the request of the government, erected
this station (Fig. 2) in 1932 under the leadership of
De Meillon for research5 and Annecke for control.17,18 Another station was established
in Eshowe, Natal, in 1934. These stations were to provide the
basic facilities for De Meillon to demonstrate the utility of
indoor spraying with pyrethrum as a highly effective measure
against adult, indoor resting anopheline mosquitoes.12,13

Fig. 2. The malaria station in Tzaneen,
1932.

2.1 Natal

Severe malaria epidemics occurred in Natal from 1929 to
1933. During this time, railway construction and sugar
production came to a standstill and almost one million quinine
tablets were distributed by the health authorities. During the
1931 malaria transmission season, cases were reported from as
far south as Port St Johns and in 1932 there were 22 132
deaths from malaria.5,19 The 1933 Annual
Report of the Union Government Department of Public Health
refers to 15 malaria committees in the Natal coastal areas and
voluntary farm groups in the midlands who supervised the
mosquito control measures. Training courses were held for
malaria inspectors and mosquito ‘spotters’. Similar measures
were implemented in the rural areas where the chiefs,
officials, missionaries and storekeepers were involved. By
1941/42, 35 800 huts were being sprayed weekly with
pyrethrum, protecting over 100 000 people.

A Pan-African Health
Conference was held in Johannesburg in 1936 under the auspices
of the Health Organization of the League of Nations. Two
papers were delivered describing the 1930 - 1933 major malaria
epidemics in Natal and Zululand and the effects of
insecticides for bringing it under control.13,16

Park Ross16 described in great detail the
malaria control activities in place from 1930 onwards. While
he was cautious in drawing conclusions from the available
data, it nevertheless appeared that administration of quinine
and the use of anti-larval measures were unsuccessful. Park
Ross referred to larviciding as ‘wasting time’ and the
distribution of quinine among a population not trained to use
the drug as unreliable. On the other hand, the use of
insecticide sprays had resulted in a dramatic drop in the
number of malaria cases, terminating the epidemic.
Furthermore, adult mosquito control was far more economical
than larviciding13 and more acceptable to rural
communities as it did not impact on water supplies for
themselves and their cattle.

De Meillon’s13 contribution to the conference
was extremely brief, perhaps overly so, outlining controlled
experiments carried out in Eshowe from December 1934 to May
1935. A rural area was divided into 4 sections: (i)
each hut sprayed daily with pyrethrum in kerosene; (ii)
each hut sprayed bi-weekly; (iii) each hut sprayed once a week;
and (iv) unsprayed control huts. The
results are summarised in Table 1.

It is clear that daily
spraying with pyrethrum had the most beneficial effect with a
91% reduction in the spleen rate, despite a 2.86% sporozoite
rate. The economics of anti-adult spraying compared with
larviciding showed that spraying cost about a third of the
cost of larviciding and reduced the spleen rate by 50%. In the
area being treated with larvicides the spleen rate actually
went up.13

Dr Fred Soper from the
Rockefeller Foundation attended this League of Nations
conference and afterwards visited the malaria research station
at Eshowe. He rejected the concept of vector control by indoor
insecticide spraying stating that for every female anopheline
that came indoors, there would be hundreds outdoors and out of
reach of the insecticide.5 De Meillon’s work12 showing that the indoor resting
proportion of the mosquito populations were the ones infected
with parasites, was ignored. Soper, however, just a few years
later, made excellent use of the very same indoor spraying
strategy to rid Brazil of An.
gambiae.20 He subsequently met Professor
James Gear from the SAIMR at a Rockefeller Institute meeting
and asked him to convey his apologies to the South African
‘malaria officers’.5

Sir Gordon Covell, on the
other hand, also a participant at the League of Nations
conference, immediately recognised the enormous benefits of
the work being done in SA. At the time he was with the British
Army in India and on his return to that country implemented a
similar control strategy with great success.21

The distribution of malaria is
illustrated in a 1938 map produced by the Department of Public
Health (Fig. 3) showing the endemic areas, with epidemic malaria
occurring as far south in the Transvaal as Pretoria and in Natal
to beyond Durban.

Fig. 3. Malaria in South Africa, 1938.

2.2 Transvaal

Prior to the Pan-African Health Conference in 1936, De Meillon
had been carrying out extensive studies in the Tzaneen area of
the northern Transvaal. Here he showed that the vector
mosquitoes rested indoors for several days after taking a blood
meal before leaving the house to lay eggs.12 This led
directly to the strategy of indoor house spraying used globally
when residual insecticides such as
dichlorodiphenyltrichloroethane (DDT) became available after
World War II.

The early work of Annecke in the Transvaal, from the time that
the malaria station was established in 1932 until the early
1940s, consisted mainly of advocacy and training – teaching the
communities how to protect themselves through treatment,
improved housing construction, screening and insecticidal
spraying. Over 600 depots were established in rural areas to
provide free quinine to the communities. Annecke states: ‘Those
who took notice (or who possessed the means to do so) lived
mostly malaria free’. 22 The vast majority, however,
suffered enormously with hundreds of deaths recorded annually
throughout the Transvaal Lowveld. Annecke carried out these
activities initially with the help of three health inspectors,
two lady health visitors, one technical assistant and four
‘spotters’. Between 1937 and 1944 the staff complement was
increased to 14 health inspectors, four lady health visitors and
three technical assistants. ‘Propaganda was intensified but did
not yield greatly improved results’22 and major malaria epidemics
were recorded in 1939 and 1943. During the 1939 epidemic,
9 311 malaria deaths were reported in the Transvaal.

It was not until 1944 when
the Farmers’ Union made urgent appeals to the government for
help that things started to change. The first meeting between
the Farmers’ Union representatives and the Secretary for
Public Health took place on the Springbok Flats, an area
devastated by the 1943 malaria epidemic to a point where huge
crop losses were experienced because labour could not be found
to reap the crops. Amid soaring global food prices, many
farmers in this area were facing bankruptcy and land values
had plummeted. 22 With a substantial grant from
Treasury, Annecke, together with the local farmers, embarked
on a full-scale malaria control operation using pyrethrum
knockdown insecticide for adult mosquitoes (DDT being very new
and in short supply) and oil for larviciding. This programme
functioned for three years but malaria had already virtually
vanished one year after operations began. Annecke recorded
that this operation was carried out with no guidance on
appropriate staffing and materials.22

Treasury almost trebled the grant
for the malaria programme in 1944/45 and Annecke rolled out
vector control to as much of the Transvaal Lowveld as existing
staffing allowed. DDT for house spraying was introduced in 1945.
The results were dramatic.

3. Post World War II, 1945 - 1950

In the spring of 1944
towards the end of World War II, field trials in the Nile
Valley and Naples, Italy, demonstrated the usefulness of DDT
to control malaria as well as louse-borne typhus. Initially
the formula for DDT was a closely guarded military secret but
a member of the South African Medical Corps, Major Neil
Murray, found it in Popular
Mechanics.3

The South African
Government was quick to realise the potential of DDT for
public health purposes and the feasibility of producing it in
the country was investigated. It involved close liaison
between the Departments of Public Health, Defence and
Agriculture, with assistance from the British and American
Governments.23 This led to the construction of
a manufacturing plant at Modderfontein outside Johannesburg,
where large amounts of DDT were produced. 3 Its first use in SA was to
control an outbreak of typhus in the Middleburg district of
the Transvaal, achieving such dramatic success that it was
made freely available to people in the Transkei who were
experiencing a similar outbreak. After discussion with Prof.
James Gear and Dr Botha de Meillon, Dr Eksteen, Member of
Parliament for Middleburg, proposed in Parliament that DDT
should be used for malaria control by indoor house spraying.3

3.1 Initial trials with DDT

The first SA trials with DDT were conducted in the Transvaal
and described by Annecke in the 1945 Department of Public Health
annual report.23
He received the first shipment of DDT in mid-1944 – a very small
quantity that proved to be insoluble, even in kerosene,
resulting in ‘no conclusive work’. At the beginning of 1945, a
new formulation was received resulting in less clogging of the
spray pumps. Between October 1945 and June 1946, extensive field
trials were conducted in various localities around Tzaneen. A
comparison was made between DDT sprayed and unsprayed huts at
Thabina, with a considerable reduction in vectors caught in the
huts (Table 2). Cost comparisons were also made between DDT
spraying and weekly pyrethrum spraying, indicating that weekly
spraying was up to 20 times more expensive than DDT spraying.
The results of the Thabina trials, as well as similar trials at
Hlabisa in Zululand comparing DDT with weekly pyrethrum spraying
(Table 3), were published in 1946. 24 This report concluded:
‘Experiments so far carried out indicate that the application of
a 5 per cent DDT solution (in kerosene) offers a more economical
and effective method of malaria (mosquito) control in … rural
areas than any other method previously tried by this
Department’.24

During these trials, comparisons were also made between DDT 5%
in kerosene and malaria oil, both used as larvicides. These
trials also included experimental attempts to spray DDT on water
by means of an aircraft. The results of these trials were
inconclusive, as it did not demonstrate residual benefits of
DDT.

The results of these studies paved the way for introducing and
expanding vector control in 1946 through indoor residual
spraying (IRS), offering far better results than previously
achieved through weekly indoor space spraying. The coverage was
extended to areas not formerly controlled including many rural
areas.25
Annecke summarised the malaria control programme in the
Transvaal as follows:22

• ‘Larviciding
(using oil, but busy replacing oil with DDT emulsion) applied
fortnightly in summer to all breeding places and monthly in
winter, to the proven winter breeding sites’.

• ‘Larviciding is
combined with the use of a residual insecticide. 5% DDT in
kerosene was used in westernised houses, with 50% DDT wettable
power in traditional houses. DDT was applied every 3 to 4
months. In the epidemic prone or low risk areas, DDT was used
alone, applied once or twice a season’.

In the Transvaal, the operations were mostly implemented by the
Union Department of Public Health, with a vertically structured
malaria control unit, administratively divided into five zones.
In Natal, malaria control was implemented through ‘Statutory
Malaria Committee’ areas, with activities paid through refunds
to the committees, by the Department of Public Health.

The other major contribution made by De Meillon in these early
years was the detailed descriptions of the anopheline mosquitoes
of sub-Saharan Africa.26,27 These works were
invaluable for the malaria vector control programmes’
surveillance activities, enabling accurate identification of the
vector species.

4. The eradication era, 1950 - 1970

The impact achieved through of IRS of houses was widely lauded
and documented. Various indicators were used to demonstrate the
successes, among these a reduction in vectors collected in
dwellings, decline in the use of quinine, parasite and spleen
rates, and the economic benefits. In 1951, Annecke reported
extensively in the Department of Public Health’s annual report
on the impact of IRS in the Transvaal.28 The use of 5 grain quinine
tablets dropped from 2 000 000 in 1943/44 to
94 000 in 1950/51. The dramatic decline in parasite and
spleen rates between 1931 and 1951 is shown in Table 4. This was
based on blood smears taken from the local population at the
peak of the malaria season outside Tzaneen, Transvaal.

In 1952, the Minister of Health for the Union of SA, gave a
radio broadcast on the economic benefits modern malaria control
had brought to the Transvaal: ‘… 10 000 square miles
containing some of the country’s richest farming land in the
world for sub-tropical fruit; yet only fifteen years ago this
area was shunned by Europeans, and those [locals] who survived
to young adult life lay ill in the kraal just when they should
have been reaping their crops. In the hyper-endemic zones of
Pongola – a few years ago almost a deserted region – the
disappearance of malaria gives a fair chance that within five
years the area will be producing about 20% of the sugar cane
grown in the Union’.29

Several threats to the continued success of the malaria
control programme were perceived, among these vector
resistance to insecticides and parasite resistance to
treatment. Cross-border malaria was also highlighted as a
major threat for the ongoing programme success. In the
Transvaal, transmission was affected by poor control in
Bechuanaland (Botswana), Southern Rhodesia (Zimbabwe),
Mozambique and Swaziland. In Natal, the impact that
uncontrolled areas were having on controlled areas was
reported on many occasions. In 1953, an outbreak in the
Nongoma and Hlabisa districts in Natal was attributed to the
lack of control in the adjacent rural areas, as Malaria
Committees were not in place in these areas. This prompted the
expansion of control measures to Ubombo and Ingwavuma in 1953.
By 1956, malaria infections had been reduced to negligible
figures.30

Towards the end of 1959, a WHO assessment team visited the
malarious provinces in SA and a full appraisal of the malaria
situation in the country was made, with resulting
recommendations towards the eradication of malaria in the
country.31

The assessment team recommended that Natal be divided into
three zones, namely the transmission zone (northern parts of
Natal), the consolidation zone and the vigilance zone. For the
transmission zone, the full-scale attack phase of an eradication
programme was recommended, with total residual insecticide house
spraying coverage throughout the area. The high levels of
malaria in southern Mozambique were highlighted as a threat. As
the border with Mozambique was only a geographical boundary
line, free movement of people took place, without any
administrative formalities. The establishment of checkpoints
along the Mozambique border, to intercept migrants and
administer treatment was considered. Mozambique was also
preparing to introduce a malaria eradication programme, which
would provide protection to Natal.

For the consolidation zone, IRS was to be discontinued and
retained only as an emergency measure, with the implementation
of a surveillance system. As there was no evidence of malaria
transmission in the vigilance zone, from 1954 this area was
considered to be clear of malaria with ongoing surveillance
recommended.

For malaria control purposes, the Transvaal was divided into
four zones as confirmed by the WHO team, with malaria
transmission only occurring in zone 1 (the north-eastern Lowveld
areas) and zone 4 (Bushbuckridge, Nelspruit, Komatipoort and
Barberton). In the other two zones, only sporadic cases of
malaria were reported, with spraying discontinued and control
maintained through selective larviciding. However, with the
influx of parasite carriers from Zimbabwe and Mozambique still
occurring, the need for implementing malaria eradication
projects in these neighbouring countries as part of the
south-east Africa malaria eradication programme was essential.
It was recommended that IRS be continued in the transmission
zones and that the cessation of IRS should depend upon progress
in the adjacent countries.

All research on malaria vectors had ceased with the
widespread implementation of IRS in the 1950s. De Meillon had
been told by the Director of the SAIMR to stop working on
mosquitoes because the malaria problem had been solved (Botha
de Meillon, personal communication). Elsewhere in Africa,
however, interesting observations were being made on the
vector mosquitoes that would lead to a much better
understanding of apparent ‘failures’ of vector control in
southern Africa. Among these pioneers was a South African,
Hugh Paterson (Fig. 4), working then for
the SAIMR arbovirus unit, who in his spare time studied
malaria mosquitoes. He was one of the key figures in
unravelling the An. gambiae
complex, demonstrating that at least three fresh-water
breeding species existed and that one of them fed only on
cattle and did not transmit malaria.32
This formed the basis for all subsequent research on these
important vectors and explained anomalies like that found in
Swaziland where indoor spraying had apparently caused the
mosquitoes to change their behaviour from biting humans
indoors to biting cattle outdoors.

From 1960 to 1966, the endemic malaria areas in the Transvaal
and Natal experienced a severe drought. As the conditions did
not favour the breeding of vector mosquitoes, malaria was at
very low levels during this period. After the prolonged drought,
heavy rains fell in 1967, resulting in conditions favouring the
breeding of An. gambiae in
temporary pools and An. funestus
in small perennial streams. A sharp, but restricted epidemic
occurred in the Komatipoort area of the eastern Transvaal, the
first since the mass control campaign was undertaken in 1945.3,33 In
1969, malaria transmission increased in the north-eastern
Transvaal where house spraying had been discontinued due to the
low number of cases. House spraying with DDT was reintroduced
but the lack of qualified and experienced entomological
personnel was recognised as a major problem. Mr Gideon van Eeden
(Fig. 4), having just returned from Swaziland where he obtained
extensive entomological training under Dr O Mastbaum, was the
only employee available to undertake entomological monitoring.

5. Malaria under control, 1970 - 1995

Widespread rains over a prolonged period in 1971 - 1972
resulted in a severe and extensive epidemic during 1972.c Due to
insufficient personnel and delays caused by the rain, house
spraying was not completed and patients with malaria could not
be adequately traced. In the Komatipoort area, the sugar cane
industry was being constructed with land clearing providing
suitable larval breeding habitats. Migrant workers housed
themselves in plastic bag shelters and were exposed to vectors.
Over 3 700 indigenous malaria cases were confirmed
throughout the Transvaal and at the peak of the epidemic, 600
infections were confirmed in a single week from Komatipoort.

The epidemic sparked a
debate in the National Assembly. While the Minister of Health
explained the epidemic as being ‘under control’, he did commit
to visiting the malaria control areas and proposed the
strengthening of the programmes. There was also an undertaking
to take the matter up with the neighbouring countries
Mozambique and Rhodesia (Zimbabwe), as these two countries
appeared to contribute to the problems in SA.d

This resulted in the number
of malaria teams being almost doubled and allowed for the
construction of an insectary at Tzaneen in 1972. It also
resulted in a visit from the WHO, whose representatives spent
a week in the northern Transvaal assessing the situation. The
outcome was that three senior WHO personnel were posted to
Tzaneen from 1973 to 1976 – a medical malariologist (Dr J
Lilyveld), an entomologist (Dr A Smith) and a
malaria technical officer seconded from USAID (Mr J Thompson).
In 1973, the National Department of Health (DoH) revived the
‘malaria office’ at Tzaneen with a medical officer (Dr Frank
Hansford; Fig. 5), two entomologists (Dr Neethling du
Toit and Mr Gideon van Eeden) and field and laboratory staff
to assist the WHO team. The Tzaneen ‘malaria office’ became
known locally as the ‘Siegfried Annecke Institute’, but was
officially named the National Institute for Tropical Diseases
in 1979, and was responsible for malaria control in all the
malarious regions of SA. At the same time, Botha de Meillon,
then in his 70s, was employed as a consultant to assist with
entomological investigations. Capacity for identifying the
members of the An. gambiae complex was increased through
the establishment of an electrophoresis laboratory in Tzaneen,
set up with the help of the Rhodesian entomologists who had
developed the method.34 Chris Green (Fig. 6) and
Richard Hunt (Fig. 7) subsequently joined the Department of
Medical Entomology, SAIMR, in 1978, thereby strengthening the
research capacity on malaria vector mosquitoes. Further
capacity for entomological research was created by the SA
Medical Research Council (MRC) at their Research Institute for
Diseases in a Tropical Environment in Durban. Brian Sharp was
employed in 1980 and was later joined by David le Sueur (Fig.
7). Together, they set up the Lubombo Spatial Development
Initiative (LSDI) Malaria Control Programme in 1999, described
below.

In 1978, again following
heavy rains, a severe epidemic occurred in an unsprayed area,
Bolubedu, east of Tzaneen, with 1 468 cases reported in
April of that year. Again, additional resources were made
available for malaria control, this time to the Lebowa
government (one of the newly established ‘homelands’).35 Subsequent to the outbreak, all
dwellings were sprayed and in spite of extensive surveillance,
no infections were found the next year.

Apart from these two
epidemics, malaria cases seldom exceeded the 4 000 case
level until the mid-1980s when: (i) chloroquine drug resistance
was detected in the parasites in Natal,36-38 and (ii)
migration from Mozambique increased due to political
disturbances in that country (Fig. 8). This resulted in annual
cases being consistently over 6 000 for six consecutive
years, reaching over 10 000 in two of them. Once
first-line treatment in Natal was changed to
sulphadoxine-pyrimethamine malaria transmission reverted
briefly to previous levels (Fig. 8), but resurged again in
1993 when chloroquine resistance was detected in the Transvaal
and climatic conditions favoured mosquito breeding.

In the 1980s, new
insecticides became available for malaria vector control.
Synthetic pyrethroids were developed for both IRS of houses
and for treating bednets, while carbamates were adapted for
house spraying. Pyrethroids in particular were tested
extensively for their residual efficacy to see if they could
replace DDT, which had become unacceptable to the local
communities because of increased resistance in the bedbug
populations39 and the marks left on the walls
after spraying.40,41 DDT had also received negative
press regarding its persistence in the environment and in the
food chain. By 1994, the SA National Malaria Control Programme
had decided to change policies and switch from DDT to
pyrethroids for IRS, and this change came into effect in 1995.42

Also, in 1994 there was a change
of government in SA, with a redrawing of the provincial
boundaries resulting in the central malaria control programme
run from Tzaneen being devolved to the four malarious provinces:
KwaZulu-Natal (KZN), Mpumalanga (former Eastern Transvaal),
Limpopo (former Northern Transvaal) and North West (former
South-Western Transvaal and Northern Cape) provinces. Kobus la
Grange, one of the managers for the Mpumalanga programme,
subsequently went on to manage Phase 2 of the LSDI
programme in Mozambique before his death in 2009.

The DoH established a Malaria
Advisory Group in 1994 comprising of the SA Malaria Control
Programme manager under the leadership of Dr Neil Cameron,
Director for Communicable Diseases, key control programme
personnel such as the regional managers and entomologists,
research institutions and the military. Prof. Jan van den Ende,
the Director of the SAIMR, chaired the committee. This group
provided guidance and advice on malaria control policy and
strategy and was to play a key role in the epidemic of
1999/2000.

6. 1996 - present

Along with the policy change in 1995 to move away from the use
of DDT for IRS, border controls were relaxed, particularly on
the northern KZN/Mozambique border, resulting in many rural
Mozambicans travelling to SA in search of treatment for illness,
including malaria. Rainfall was also particularly good during
this period. This combination of events saw the number of
malaria cases leap from 8 750 in 1995 to 27 035 in
1996 and remain there for the next two years (Fig. 9). In
1999, the number of cases doubled to 51 444 and in 2000 hit
a peak of 64 622, the highest number of cases recorded
since the introduction of DDT for IRS.

Fig. 9. Malaria cases in South Africa,
1995 - 2012 (data from the National Department of Health).

Entomological investigations carried out in northern KZN
Province by Keith Hargreaves, in collaboration with
entomologists from the SAIMR, showed that An. funestus had returned to SA and was
resistant to the pyrethroids being used for IRS.43 Out of 52 mosquitoes collected
along the Mozambique border, 5.4% were infected with P. falciparum. Furthermore, in 2000 it was
shown that the first-line drug for treatment of malaria in SA,
SP, was failing. On the recommendation of the Malaria Advisory
Group, DDT was reintroduced for the spraying of traditional
structures, while pyrethroids were maintained for westernised
housing, effectively implementing a mosaic strategy for
resistance management. The following year,
artemisinin-containing combination treatment (ACT) was
introduced for treatment of the disease.

SA’s decision to reintroduce DDT to control the epidemic was
made in the face of considerable pressure against the
insecticide, and indeed against all insecticides. Similarly, the
country’s decision to adopt the use of ACT was made at a time
when the WHO had not changed official treatment policy, and did
not issue new treatment guidelines for another 6 years. Not only
had the WHO encouraged countries to reduce their reliance on
insecticides, no major donor agency would sanction the use of
DDT in any IRS programme. In 2000, at the height of SA’s malaria
epidemic, the Stockholm Convention on Persistent Organic
Pollutants, held its fifth and final negotiating committee
meeting in Johannesburg. National government, with the
assistance of international scientists and an independent
advocacy group, succeeded in securing an exemption for not only
the South African National Malaria Control Programme but all
national malaria control programmes wishing to use DDT for
malaria vector control purposes.

6.1 The
Lubombo Spatial Development Initiative

The LSDI Malaria Control Programme was officially inaugurated
in October 1999 by the signing of a protocol by the Ministers of
Health of the three countries: SA, Swaziland and Mozambique. The
signing of this protocol established the Regional Malaria
Control Commission, comprised of malaria scientists and control
and public health specialists from the three countries. The
overall objective of the LSDI was to reduce the incidence of
malaria in Maputo Province in southern Mozambique and thus
contribute to its reduction in the adjoining border areas of SA
and Swaziland. Under the leadership of Brian Sharp from the MRC,
this programme was rolled out with the financial support of the
Global Fund to Fight AIDS, TB and Malaria. Initially, vector
control using IRS of houses with pyrethroids was planned.
However, subsequent to the demonstration by SAIMR and KZN
entomologists in northern KZN Province that the An. funestus vector population was
highly resistant to pyrethroids,43 work was carried out by
Richard Hunt and Graham Kloke at the Mozal Aluminium Smelter in
Maputo, Mozambique, confirming both pyrethroid and carbamate
resistance in An. funestus
populations in southern Mozambique.44 Nevertheless, bendiocarb
was used for IRS in southern Mozambique starting in 2000.
Despite the fact that the An. funestus
population showed low levels of resistance to bendiocarb, during
the period 1999 - 2005 the parasite prevalence rate in the human
population decreased from 65% to 4%.45

6.2 Capacity
building and other regional collaboration

The African Regional Office of the WHO created the African
Network for Vector Resistance (ANVR) in 1999. This initiative
was used to increase awareness of insecticide resistance in the
vector mosquitoes in all the malarious countries in the WHO-Afro
Region. Training courses in vector resistance and resistance
management were held at the SAIMR in Johannesburg annually from
2000 to 2003 for Anglophone countries, while similar courses
were held in Cameroon for French-speaking countries.
Approximately 80 people from 40 African countries were trained
in basic vector control entomology during this initiative.

South Africans have been key participants in many expert
regional and international committees over the decades. These
began with De Meillon and Park Ross’ participation in the League
of Nations meetings prior to World War II and De Meillon’s
appointment as a WHO consultant in Brazzaville in the 1960s.
Currently, SA is represented on the Roll Back Malaria Vector
Control Working Group (M Coetzee and R Maharaj), the Stockholm
Convention DDT Expert Committee and the WHO Global Malaria
Programme’s Technical Expert Group (M Coetzee), and the WHO
Global Malaria Programme’s Treatment Guidelines group (K
Barnes). The SA National Malaria Control Programme personnel
participate on SADC and WHO/AFRO committees that consider
malaria as a regional problem. Not least, the immensely popular
SA singer, Yvonne Chaka Chaka, holds the appointment of UN
Goodwill Ambassador for Malaria.

7. Conclusion

Over the past 100 years, SA has made enormous strides in
controlling the transmission of malaria, particularly since
World War II and the advent of DDT for house spraying. Probably
the most important lesson learned over the years has been the
need for constant vigilance and surveillance of vectors and
parasites. Where these have faltered, we have seen increases in
transmission, sometimes dramatically so, as in the 1999 - 2000
epidemic.

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